2017-18 HSC Section 4 Green Book

Evidence-Based Facial Fracture Management

investigated with several RCTs ( Table 3 ) attempt- ing to determine the ideal method of fixation. Danda 17 conducted 1 such trial by comparing postoperative complications between angle frac- tures repaired with a standard Champy plate and fractures repaired with a Champy plate plus a sec- ond plate on lateral aspect of the mandible. In this study, with 27 subjects in each group, there was no difference in complication rates. He concluded that there is no benefit to using a second plate for noncomminuted angle fractures. Siddiqui and col- leagues 18 also compared plating requirements for angle fractures. This RCT again compared using 1 miniplate (n 5 36) to using 2 miniplates (n 5 26) for noncomminuted angle fractures. There was no dif- ference in total morbidity or complications between the techniques. The investigators concluded that 2 miniplates offered no additional benefit and increased costs. In a larger RCT found in the facial fracture litera- ture, Laverick and colleagues 19 compared angle fractures repaired with a traditional Champy plate along the oblique ridge with repairs using a later- ally placed plate with a transbuccal approach and percutaneous trocar. In this study of 261 frac- tures, the transbuccal lateral plate had a much lower postoperative infection rate (5%) than those placed along the oblique ridge (20%). The lateral plates were also far less likely to need removal for infection. The results showed that transbuccal lateral plating did not require longer operative times and was associated with fewer complica- tions. The investigators recommend using this technique for all angle fractures for which a Champy plate would have otherwise been used. Sugar and colleagues 20 studied 140 consecu- tive subjects undergoing repair of mandibular angle fractures. They compared complications

with standard intraoral plating along the oblique ridge with intraoral plus transbuccal plating along the lateral boarder. The study found, based on the measured outcomes of plate removal and infection requiring further surgery, that the com- bined transbuccal-oral procedure was safer and more effective than the standard intraoral tech- nique. The investigators also showed, using a sur- geon survey, that it was overwhelmingly preferred by the surgeons who performed both procedures. Despite the appearance of these randomized tri- als in the recent literature, proving the superiority of any particular plating technique will continue to be a challenge to surgeons. These referenced randomized trials were mostly of small sample size and reported several outcome variables in a nonstandardized manner. The findings from these studies were in some cases conflicting. Until larger, better-designed, and more standardized clinical trials are conducted, surgeons must use caution when interpreting this literature and applying it to patient care. Even when there is agreement on the fixation for a particular type of fracture, there is a wide range of opinions about the need for postoperative MMF. The duration of MMF is influenced by many clinical factors, including fracture location, fracture severity, and anticipated patient compli- ance. There is only limited lower level evidence to determine an optimal length of MMF. Recently, Adeyemi and colleagues 21 conducted an RCT comparing the standard 4 to 6 weeks of MMF with a treatment group receiving only 2 weeks. The investigators found that both groups healed their fractures but recovery of full mouth opening was more rapid with a shorter period of MMF. In another study addressing the duration of MMF, Kaplan and colleagues 22 compared mandible

Table 3 Mandibular angle fracture repair randomized controlled trials

Study

Question

Result

Conclusion

Danda, 17 2010 1 vs 2 miniplates for

No difference in complication

No benefit to second plate

noncomminuted fracture 1 vs 2 miniplates for noncomminuted fracture Traditional Champy plate vs lateral plate via transbuccal Traditional Champy plate vs lateral via transbuccal

Siddiqui et al, 18 2007

No differences in total morbidity or complications Much lower complications with lateral plate

No benefit and increased cost with second plate

Laverick et al, 19 2012

Lateral plate favored over Champy

Sugar et al, 20 2009

Fewer complications with lateral plate

Lateral plate favored over Champy and preferred by surgeons

Data from Refs. 17–20

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